Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch

Objectives This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch. Methods Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed. Results No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up. Conclusions The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

Abstract 1122‐000101: First‐in‐Human Experience Using the Millipede 088 Aspiration Catheter in Stroke Thrombectomy

Introduction : Studies have suggested that closely matching the catheter size to the vessel size may improve the effectiveness of clot aspiration in stroke thrombectomy. A new category of “super‐bore” aspiration catheters with 8Fr OD and 0.088in ID has recently been developed to further improve reperfusion success. In this work we report on early clinical experience using a CE Marked device called Millipede 088 developed by Perfuze (Galway, Ireland). Methods : The clinical, procedural, and radiological data were reviewed for consecutive cases in which Millipede 088 was used. Millipede 088 was navigated to the target vessel over a 6F intermediate catheter with or without a microcatheter and microwire, at the discretion of the physician. Performance was evaluated in terms of successful intracranial navigation and reperfusion measured using the mTICI scale. Results : Ten patients (age 55–89 years, 50% male) with intracranial large vessel occlusions (LVOs) were treated ‐ 4 ICA and 6 M1 LVOs. In two cases, the patients had concomitant tandem lesions requiring additional treatment. Millipede 088 was delivered intracranially in all cases, and to the target vessel in 8 cases. In two cases in which Millipede 088 was not advanced to the target vessel, it was placed intracranially for distal flow control, and an intermediate catheter was used for clot aspiration. In one case, following mTICI 2b reperfusion after aspiration, a stentriever was deployed via Millipede 088 to retrieve a distal M2 clot. Excellent reperfusion (mTICI 2c‐3) at the end of the procedure, was achieved in all (100%) of patients. First‐pass mTICI 2c‐3 was achieved in 5 patients (50%). No sICH or other complications were reported. Conclusions : In this first in man experience, aspiration thrombectomy using the Millipede 088 proved to be technically feasible and safe. Excellent reperfusion was achieved in all patients. The Millipede 088 represents a promising option for stroke thrombectomy.

Repeated Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Management: Case Report

Aim: Middle Meningeal Artery (MMA) embolization has emerged as a viable neuroendovascular technique for the management of chronic subdural hematoma (SDH). Comparative analysis of various endovascular techniques for embolization is lacking. Guidance on operative techniques in situations of prior embolization failure is rare. Materials and Methods: In this case report, we present a patient with a chronic subdural hematoma that failed previous coil embolization of the MMA. Digital Subtraction Angiography showed the previously placed coil and continued distal flow to the dural membranes. Results: Onyx liquid embolization was completed successfully, effectively halting both anterograde flow to the MMA and retrograde flow from external circulation collaterals. Conclusion: This case report suggests that in situations of MMA embolization failure, follow-up angiography may be completed to determine if further embolization through other procedural techniques may be possible. The angiographic images contained here highlight the advantages of liquid embolization over coil embolization of the MMA in halting SDH angiogenesis.

Successful percutaneous treatment of occlusive spontaneous coronary artery dissection with a ‘pull-back injection technique’: case report

Background Spontaneous coronary artery dissection (SCAD) is a rare condition that can cause acute coronary syndrome, typically in young patients without classical cardiovascular risk factors. Although in SCAD the conservative management is preferable, in cases with complete occlusion of the artery an invasive treatment may be required. In such cases, the goal of the percutaneous intervention should be to restore the connection between the true and false lumen recovering the distal flow of the vessel. Case summary A young man was admitted with acute chest pain and ST segment elevation in precordial v3–v6 leads. An emergent coronary angiogram showed an abrupt occlusion of middle left anterior descending artery compatible with SCAD. A microcatheter was advanced distally into the artery and pulled back with continuous contrast injection through the catheter, restoring the distal flow with a residual spiroid intimal flap and with relief of the chest discomfort. A computed tomography performed during admission showed complete resolution of the lesion. Discussion In SCAD with complete occlusion of the vessel, the ‘pull-back technique’ with continuous vigorous injection of contrast through a distal microcatheter may be effective to restore the distal flow enabling the healing of the artery at follow-up and avoiding the stent implant.

Maximizing the catheter-to-vessel size optimizes distal flow control resulting in improved revascularization in vitro for aspiration thrombectomy

BackgroundBalloon guide catheters (BGCs) achieve proximal flow control during thrombectomy but antegrade intracranial flow often persists via the Circle of Willis. Closely sizing an aspiration catheter to the target vessel might achieve greater flow control and improve technical performance. Our objective was to measure the impact of aspiration catheter size on distal flow control and flow reversal with and without the use of BGCs. Clot retrieval testing was performed to establish the impact of these parameters on revascularization.MethodsAn in vitro thrombectomy model replicated in vivo conditions. Flow was measured continuously using ultrasonic flow sensors placed 20 cm distal to the catheter tip in the middlel cerebral artery (MCA). Four aspiration catheters of increasing size were evaluated: ACE 60 and 64 (Penumbra), SOFIA Plus (MicroVention), and Millipede 088 (Perfuze). Two clot analog types (red blood cell-rich and fibrin/platelet-rich) were used for clot retrieval testing.ResultsThe larger area of the ‘superbore’ Millipede 088 catheter resulted in a larger reduction in antegrade flow than standard aspiration catheters, even when the latter were combined with a BGC. During aspiration, 6Fr catheters were unable to cause flow reversal in the distal MCA while the Millipede 088 achieved significant distal flow reversal (−146 mL/min) (P<0.0001*) (*denotes significance). The solo use of Millipede 088 resulted in better recanalization outcomes and significantly reduced distal emboli for internal carotid artery (P=0.015*) and MCA (P=0.014*) occlusions compared with all other devices and combinations.ConclusionsMaximizing the catheter-to-vessel size facilitates near flow-arrest on catheter insertion, potentially negating the need for a BGC. A 0.088 inch aspiration catheter enables significant flow reversal in the distal MCA during aspiration.

Bidirectional endovascular treatment for axillary artery injury secondary to proximal humerus fracture: a case report

Background Axillary artery injury secondary to proximal humerus fracture is a rare but serious complication. The management of this injury has traditionally involved surgical treatment. Case summary A 66-year-old female with gait disturbance slipped and fell off her wheelchair at home. She presented to a local hospital with right shoulder pain and was subsequently urgently transferred to our hospital by helicopter because of suspicion of axillary artery injury. Computed tomography angiography revealed disruption of the right axillary artery. We decided to perform endovascular treatment instead of surgical treatment for axillary artery injury. However, since endovascular treatment via the right femoral artery was impossible, we performed bidirectional (right femoral and right brachial artery approaches) endovascular treatment. We expanded the occluded lesion using a 3.5 mm × 40 mm sized balloon and placed a 5.0 mm × 50 mm stent graft (Gore® Viabahn®) across the lesion. The final subclavian injection confirmed that distal flow to the brachial artery was preserved and that there was no leakage of contrast medium from the axillary artery. Discussion We performed endovascular treatment for axillary artery injury secondary to proximal humerus fracture. Although surgical repair is typically performed for this kind of injury, our experience suggests that endovascular treatment might be an option in patients with axillary artery injury.

Carpal Tunnel Syndrome Versus Vascular Access Induced Hand Ischaemia

Hand pain is a common complaint in the hemodialysis patient on arteriovenous fistula. The problem is related to its etiology: nervous or vascular, which requires different therapeutic solutions. Ischaemic etiology involves a deviation of the distal flow in the anastomosed vein, with the decrease of the distal flow and the installation of distal ischaemia. Nerve etiology involves compression of the median nerve in the carpal tunnel. The purpose of the paper is to present a case study of diagnosis and treatment of median nerve compression in hemodialysis patient.

Intracranial Atherosclerosis: A Disease of Functional, not Anatomic Stenosis? How Trans-Stenotic Pressure Gradients Can Help Guide Treatment

Background Most trials have assessed intracranial atherosclerotic disease (ICAD) severity based on angiographic stenosis. However, anatomic stenosis might not accurately identify the actual state of functional post-stenotic flow limitation. Objective To investigate whether angiographic stenosis correlates with physiologic distal flow limitation, measured as trans-stenotic pressure gradients, in ICAD patients. Methods In patients referred for endovascular treatment of anterior circulation symptomatic ICAD who failed maximal medical therapy (MMT) per SAMMPRIS (Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis) criteria, angiographic luminal diameters and percentages of stenosis were correlated with trans-stenotic pressure gradients, calculated as distal/proximal pressure ratios (DPPR) and proximal minus distal pressure gradients (PDPG), by way of Spearman correlation coefficients. Results Nine patients (3 men, 6 women) were evaluated. Atherosclerotic lesions’ locations included internal carotid artery in 5 subjects (2 cavernous, 3 supraclinoid) and proximal middle cerebral artery (M1) in 4 patients. Mean percentage of stenosis was 80 ± 8% (range 75%-94%). Minimal lumen diameter at the most stenotic ICAD site ranged from 0.2 to 0.9 mm (0.59 ± 0.41 mm). DPPR ranged from 0.38 to 0.63 (0.56 ± 0.14). PDPG ranged from 35 to 57 mm Hg (50 ± 8 mm Hg). Spearman coefficients showed no correlation between DPPR or PDPG and angiographic minimal luminal diameters or percentages of stenosis. There were no procedural complications related to trans-stenotic pressure measurements. CONCLUSION Angiographic stenosis does not reflect the physiologic severity of distal flow limitation in patients with ICAD. Hemodynamic assessment using trans-stenotic pressure ratios and gradients may serve as a more reliable predictive biomarker for MMT failure and response to revascularization.